Can one have open heart surgery after a heart attack?

Hi,

Welcome to icliniq.com.

Kidney function tests of your relative are deranged (attachment removed to protect patient identity). His serum creatinine levels and potassium levels are high. What do you mean by surgery? Is that open heart surgery or stenting?

However, the surgery can be done only if kidney function tests become normal, otherwise, the patient can end up in renal failure. Right now ask the nephrologist to make his parameters stable (kidney). It will take about two days. Then, you can proceed with surgery. Emergency surgery can be done with deranged kidney functions also, but the chances of landing up in acute renal failure are high.

I hope that you get your answer.

Please let me know if you need any help.

Thank you.

Hi,

Welcome back to icliniq.com.

I have noted all the details.

The patient had a massive myocardial infarction as depicted by the ECG. His left ventricle ejection fraction is critically low only 20 percent, and his ECG is showing premature ventricular contraction, which suggests gross ischemia in the heart. Whether to go for angioplasty (stenting) or open heart bypass surgery depends on a number of factors like a number of coronary arteries blocked, location and site of blockages, etc. Kindly attach the detailed reports of angiography as the age of the patient is 58, diabetic, renal functions are deranged and the ejection fraction of the heart is critically low.

The overall mortality rate in elderly post-CABG (bypass surgery) is three to four percent. During the surgery itself, heart attacks can occur in four to five percent of patients, which may cause immediate mortality, and about five percent of elderly patients require re-exploration post-CABG due to bleeding complications. This mortality is increased, if the ejection fraction is low (only 20 percent and the normal value is more than 55 percent) or the disease involves the left main coronary artery or the patient is diabetic (as in your case).

While complication and mortality rates, post-stenting are much lower in patients with multiple morbidities, but angiography report is required before deciding whether to go for a stent or bypass. As you have asked for bypass only, I would consider that angiography must be showing something that has only bypass as an option and stenting is not possible. Making that an assumption, I would like to advise you to go for minimally invasive coronary bypass surgery - MICS CABG or MICA S stands for minimally invasive coronary artery surgery. It is a relatively new and advanced technique of performing coronary bypass for coronary artery disease.

In this technique, the heart is approached through the side of the left chest through a small 4 cm incision. This cut is placed just under the nipple. The chest is entered between the ribs without cutting any bones and by splitting the muscle. Conventional CABG or coronary bypass surgery is performed by splitting or cutting through the breastbone or sternum. MICAS is the latest advent in the field of cardiac surgeries. It is very safe and useful, especially in older patients with other chronic conditions, renal problems, and patients with very low cardiac functions.

The advantages of MICS over conventional CABG in old age patients, especially in patients with uncontrolled diabetes with recent massive myocardial infarction are as follows. All infections are reduced whether it would be wound infections or post-surgical lung infections. This makes the procedure ideal for diabetics and older patients who have poor resistance to infection. In fact, this is the biggest advantage in your case.

The risk of infection is close to zero. All infections are reduced dramatically in MICS. The blood loss is almost negligible eliminating blood transfusion in most and eliminating blood-borne infection. As the condition of the heart in your case is very poor; hence, too much blood loss should be avoided.

As no bones are cut, advantages in reducing pain, retaining function, and having a positive effect on breathing. Unlike traditional CABG where bones are cut and the patient has to suffer from a lot of pain for at least two weeks after the operation. The patient will be discharged in four days, unlike conventional heart surgery which takes 14 days.

But, I would say that I would like to see the angiography reports and if possible videos of angiography to see if stenting is possible because in patients with multiple ailments with low EF recovery post-CABG is sometimes difficult.

I hope that you get your answer.

Please let me know if you need any help.

Thank you.

Hi,

Welcome back to icliniq.com.

The mentioned surgery will be done by CTVS surgeons (cardiothoracic and vascular surgeons).

I hope that you get your answer.

Please let me know if you need any help.

Thank you.

Hi,

Welcome back to icliniq.com.

I have seen all the reports of the patients (attachment removed to protect patient identity).

In my opinion, the patient is not a good candidate for minimally invasive surgery. An ejection fraction of the patient is critically low, only 20 percent, and an angiogram shows all three major coronary arteries are critically narrowed. This patient will require at least four to five grafts.

Usually, we use a graft of LIMA (arterial graft), but arterial grafts are usually not successful when the ejection fraction of the patient is critically low. Arterial grafting through a minimally invasive technique is usually done when we need one or two grafts. So, in your case, venous grafts will be used. The life of a venous graft is about five years and venous grafting is not usually done by minimally invasive procedure.

The chances of recovery are good as the PET scan shows a viable myocardium (blood supply is hindered, but heart muscles are still alive). MICS can be done and I think the risk will be about 10% more than open heart CABG. The final decision rests with the cardiothoracic surgeon.

I hope that you get your answer.

Please let me know if you need any help.

Thank you.

Hi,

Welcome back to icliniq.com.

You have not mentioned whether the bypass of your relative was done or not. According to the reports enclosed by you (attachment removed to protect patient identity), his Trop I (troponin I) is very high. It is possible that he had a minor heart attack again.

Trop I is a very sensitive marker of cardiac muscle damage. Hence, most likely the breathlessness can be due to cardiac events. You have not mentioned the reason for his treadmill test. Also, suggestions will be different in case he is post-bypass surgery.

Please let me know if you need any help.

Thank you.

Hi,

Welcome back to icliniq.com.

His angiography reports say that complete blockage of major coronary vessels. He had a heart attack recently, and any type of exercise (even mild in nature) is contraindicated for him until the surgery is done. You said he used a treadmill, most likely he had a heart attack again because of that.

His troponin was elevated and his ejection fraction was just 20 percent. Both of them point toward him having another heart attack. Breathlessness was because of a heart attack or sudden deterioration of his cardiac functions. Kindly send me the ECG taken yesterday at CCU (coronary care unit) and a copy of the treatment, that he was taking.

I can suggest more anti-anginal till bypass surgery is done. As of now keep him in CCU till the cardiologist clears him and his breathlessness settles down fully.

I hope that you get your answer.

Please let me know if you need any help.

Thank you.